Fillable LUBBOCK COUNTY CRIMINAL COURTS APPLICATION FOR EXTENSION OF (Texas Secretary of State)

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LUBBOCK COUNTY CRIMINAL COURTS APPLICATION FOR EXTENSION OF (Texas Secretary of State)

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(COMPLETE FRONT and BACK – PLEASE PRINT) Blank answers will delay your processing.
(COMPLETE FRONT and BACK – PLEASE PRINT) Blank answers will delay your processing.
1 of 2
LUBBOCK COUNTY CRIMINAL COURTS
APPLICATION FOR EXTENSION OF TIME PAYMENT PLAN
HOW MUCH ARE YOU PAYING TODAY? $___________
A) PERSONAL INFORMATION: COMPLETE ALL BLANKS
Social Sec. # _______-________-_________ Date of Birth ____________ Race ______ Sex ______ Ht.___'____" Wt.______lbs
Color Eyes ________ Color Hair _______ Driver’s License [ ] or I.D. [ ] Number#_______________________ State __________
Name: _____________________________________________________________________________________________________
Last First Middle Go By
Mailing Address: _____________________________________________________________________________________________
Street Apt. # City/State Zip Code
Physical Address: _____________________________________________________________________________________________
Street Apt. # City/State Zip Code
Does anyone other than you live at this address? Yes
[ ] No [ ] If yes, who & relationship? __________________________________
Cell/Me
ssage Phone: ____________________ Home Phone: ___________________ Work Phone: _________________
[ ] Married [ ] Single [ ] Separated [ ] Divorced Email: __________________________________________________________
If ma
rried, Spouse’s Name______________________________________________________________________________________
First Middle Last
Spouse
’s Address & Phone # (if different) _________________________________________________________________________
Address Phone
B) CONTACTS: LIST (4) PEOPLE WHO CAN CONTACT YOU. (1) MUST BE A RELATIVE (NAMES, PHONES & RELATIONSHIP REQUIRED).
1) ___________
______________________________________________________________________________________________
Name Address Phone Relationship
2) ___________
______________________________________________________________________________________________
Name Address Phone Relationship
3) ___________
______________________________________________________________________________________________
Name Address Phone Relationship
4) ___________
______________________________________________________________________________________________
Name Address Phone Relationship
C) STUDENT INFORMATION: ARE YOU A STUDENT? [ ] YES [ ] NO IF “NO,” MOVE TO PART “D”
If yes, [ ] College [ ] High School [ ] Other Status [ ] Full-time [ ] Part-time Education (grade level completed) _______
Name
of School _______________Who pays tuition? ______________ Hours you attend school: Everyday ______to_______ or
MWF _____t
o______ or TTH ______to_______ or Other (explain): ____________________________________________________
For Office Use Only Date_______________ Total Due $____________ Court #________ Offense_____________________
Case Nu
mber_________________________________ Interviewer_______________________ Over Phone [ ] / In-Person [ ]
Std. Plan [ ] / Coll. Plan [ ] / Jud. Plan [ ] Community Service [ ] Yes [ ] No
CLEAR FORM
(COMPLETE FRONT and BACK – PLEASE PRINT) Blank answers will delay your processing.
(COMPLETE FRONT and BACK – PLEASE PRINT) Blank answers will delay your processing.
2 of 2
D) EMPLOYMENT: Are you [ ] Employed [ ] Unemployed? Spouse’s Employer: [ ] Employed [ ] Unemployed
How long? _______ [ ] Days [ ] Weeks [ ] Months [ ] Years
If employed, [ ] Part-time [ ] Full-time
If “Part-time,” approximately how many hours per week: ____
Employ
er: Name____________________________________
Address___________________________________
Phone# (_______) ___________-______________
Hourl
y wage $_________ Take Home Pay $______________
[ ] weekly [ ] bi-weekly [ ] monthly Next Pay Day ________
How long? _______ [ ] Days [ ] Weeks [ ] Months [ ] Years
If employed, [ ] Part-time [ ] Full-time
If “Part-time,” approximately how many hours per week: ____
Employ
er: Name____________________________________
Address___________________________________
Phone# (_______) __________-_______________
Hourly
wage $_________ Take Home Pay $______________
[ ] weekly [ ] bi-weekly [ ] monthly Next Pay Day ________
E) CREDITORS
List All of Your Creditors (ex. Banks, Auto Payment, Credit Card Accounts, Finance Companies, Rent-to-Own Companies, etc.)
1) _________________________________________________________________________________________________________
Company Name Balance Owed Payment Amt. (wk./mo.)
2) _________________________________________________________________________________________________________
Company Name Balance Owed Payment Amt. (wk./mo.)
3) _________________________________________________________________________________________________________
Company Name Balance Owed Payment Amt. (wk./mo.)
4) _________________________________________________________________________________________________________
Company Name Balance Owed Payment Amt. (wk./mo.)
F) ASSETS: B
ank Accounts:
Automobiles:
[ ] Checking Bank Name_____________________ Balance $__________ Year_______ Make/Model____________________
[ ] Savings Bank Name_____________________ Balance $__________ Year_______ Make/Model____________________
G) OTHER INCOME
[ ] Welfare $________
[ ] Retirement $________
[ ] SSI Retirement $________
[ ] SSI Disability $________
[ ] Unemployment $________
[ ] Food Stamps $________
[ ] Child Support $________
[ ] Other Income $________
Explain: ________________
H) EXPENSES:
[ ] Rent/Mortgage $________
[ ] Electric/Water $________
[ ] Home Gas $________
H) EXPENSES CONTINUED:
[ ] Phone $________
[ ] Other Utilities $________
[ ] Food $________
[ ] Car Insurance $________
[ ] Child Care $________
[ ] Life/Hlth Ins. $________
[ ] Child Support $________
[ ] Garnished [ ] Pay direct
[ ] Prob. /Parole $________
[ ] Tax Liens $________
[ ] Other $________
What? ______________________
All expense in you & spouses name?
[ ] Yes [ ] No
I) DEPENDENTS
How many dependents do you
support? __________
[ ] Spous
e
[ ] Child (ren)
Age
______ Age _______
Age
______ Age _______
Age
______ Age ______
[ ] Other
Relationship_____________
[ ] Other
Relationship_____________
ACKNOWLEDGMENT AND DECLARATION:
Under penalty of perjury, I hereby certify the information I have supplied is a complete and accurate statement of my current financial
condition. I authorize the Judicial Compliance Department of Lubbock County, their employees or agents to conduct a complete and
thorough investigation of my statement. I understand this investigation and subsequent contact could include direct verifications of all
information given, through phone calls, texts via auto or robodialer, or email and any other electronic means including obtaining
reports from credit reporting agencies. Upon acceptance of a standard plan, I waive my right for Judicial Compliance or its affiliates
to review my financial status. It is with this understanding, consent and acknowledgment that I formally request an extension of time
to pay assessed fines, fees and court costs now due and payable to Lubbock County. It is also with this understanding, that I accept the
terms and conditions of any and all payment or non-monetary plans.
Sworn and Subs
cribed to this _________ day of ____________________ 20______, by the Defendant.
X______________
___________________________________________
Defendant’s Signature
CLEAR FORM
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LUBBOCK COUNTY CRIMINAL COURTS APPLICATION FOR EXTENSION OF (Texas Secretary of State)

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Completed 18 July 2020

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